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Objectives: To determine the prevalence of adolescent smoking in the Russian Federation andexamine what factors are associated with it.

Methods: Data

were drawn from Round 13 of the Russia Longitudinal Monitoring Survey(RLMS) carried out in 2004. The sample consists of 815 adolescents (430 boys, 385 girls)aged 14-17 years who answered questions about their health behaviours.

Results: Smoking was more

prevalent among boys than girls (26.1 % vs. 5.7 %). Maternalsmoking and adolescent alcohol use were associated with smoking among both sexes. Theself-assessment of one’s socioeconomic position as unfavourable was associated with girls’smoking, while living in a disrupted family, physical inactivity and having a low level of self-esteem were predictive of boys’ smoking.

Conclusions:

The family environment appears to be an important determinant of adolescentsmoking in Russia. In particular, boys and girls may be modelling the negative healthbehaviour lifestyles of their parents, with unhealthy behaviours clustering. Efforts to reduceadolescent smoking in Russia must address the negative effects emanating from the parentalhome whilst also addressing associated behaviours such as alcohol use.

Keywords:

Russia; smoking; adolescent; alcohol, family environment.

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Introduction

Although adolescent smoking is widespread in every part of the world (Global Youth TobaccoSurvey Collaborative Group 2002), the prevalence of current smoking is especially high in theWorld Health Organization’s European Region (Warren et al. 2006). In particular, rates ofsmoking (among males) are extremely high in the countries of the former Soviet Union suchas Russia (Global

Youth Tobacco Survey Collaborative Group 2002). The percentage ofmales aged 13-15 who currently smoked (used cigarettes or other tobacco products on ≥ 1 ofthe preceding 30 days) was fourth highest in the Russian Federation from among 121 sitesaround the world in the period 1999-2002 (Global Youth Tobacco Survey

CollaboratingGroup 2003). Although adolescent male smoking rates were already high in the period beforethe collapse of the Soviet Union in 1991 (Hearn et al. 1991), some evidence suggests thatsmall increases nevertheless occurred in the late 1980s and through the 1990s (Tkachenko andProkhorov 1997).

The prevalence of smoking is currently much lower amongst Russian girlsthan boys, but evidence suggests that it has risen more sharply in the post-Soviet period(Rogacheva et al. 2008)–

mirroring the marked rise recorded among Russian women(Perlman et al. 2007). Such increases would also be consistent with the decrease in the age ofsmoking initiation observed in younger female birth cohorts (Perlman et al. 2007).

Moreover,one recent study has even indicated that there may now be little difference between theprevalence of boys’ and girls’ smoking in Russia (Baška et al. 2009).

It seems likely that the persistence of high rates of smoking among Russian boys andincreasing rates among Russian

girls are, at least in part, a consequence of policies pursued bytransnational tobacco corporations. Since entering the Russian market in the early 1990s theyhave focused their efforts on those segments of the population with the greatest potential formarket growth–

young people and women (Gilmore and McKee 2004). However, regardlessof the precise reasons, the current situation in Russia is deeply worrying from a public health

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perspective. Western research has linked smoking in adolescence to both smoking inadulthood (Chassin et al. 1996) and, unsurprisingly, adverse health outcomes (Strand et al.2004), with evidence suggesting that starting before the age of 15 years doubles the risk oflung cancer compared with those starting five or more years later (Peto et al. 2000). If anincreasing number of young people are now smoking, many of them heavily, it will furtherexacerbate the terrible impact that smoking already has on public health in Russia. It has beenestimated that between 1980 and 2000 nearly six million people died as a result of smoking inthe Russian Federation and currently over 300,000 deaths are attributed to smoking annually(Peto et al. 2006).

Against this background the aim of the current study is twofold. First, to determine theprevalence of smoking among 14 to 17 year olds.Second, to examine which factors areassociated with smoking among Russian adolescents. Determining which elements underpinsmoking among young people is an important first step in any attempts to stop the spread ofthis practice particularly given the importance of young people to the tobacco industry. Thekey advantage of this paper over existing studies is that it focuses on the determinants ofadolescent smoking using a sample drawn from across the Russian Federation, rather thanfrom single sites/regions as has previously been the case (King et al. 1996; Rogacheva et al.2008).

Methods

Data

The data in this study come from phase II of the Russia Longitudinal Monitoring Survey(RLMS). This is a nationally representative survey designed to determine how the social andeconomic changes that have occurred in post-Soviet Russia have affected the populationacross time. This survey is coordinated by the Carolina Population Center at the University of

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North Carolina. The present study makes use of data from Round 13 of the RLMS undertakenbetween September and December 2004.

A multi-stage (random) probability sample was used to obtain respondents from 38 populationpoints (primary sampling units [PSUs]) across Russia (containing 95.6% of the populationafter remote and/or inaccessible areas e.g. Chechnya, were removed). Moscow city, MoscowOblast and St. Petersburg city were selected as automatic sampling areas while individualdistricts from the remaining 35 PSUs

were selected using the ‘probability proportional to size’(PPS) method, i.e. the probability that a district would be selected was proportional to itspopulation size.

Within each PSU the population was stratified into its urban and rural components (second-stage units [SSUs]) with the target sample size being allocated proportionally. In rural areas alist of all villages was created to serve as the SSUs, while in urban areas the 1989 censusenumeration districts were used for the same purpose. Withinthese SSUs housing listscompiled by the researchers were used as a basis for the random sampling of addresses.

The survey collects data on both households and individuals. The information collected fromindividuals relates to such things as their employment status, demographic characteristics,anthropometry, health, and health behaviours. Individual questionnaires were administered toevery person living in the household (except for the very young and old). Those aged 14 andabove self-completed

the questionnaire

after their parents provided informed consent for theirparticipation.Household (and within them, individual) response rates have been very high atthe beginning of phase II of the survey.A fuller description of the sampling methodology is

To obtain information about adolescents’ smoking the respondents were asked, “In the last 7days have you smoked anything?” with subsequent questions clarifying that this referred totobacco. Those who responded ‘yes’ are classified as weekly smokers in the present study.

Information was also collected on a number of other variables that have been examinedpreviously in relation to adolescent smoking. Data were gathered on family structure withfamilies being subsequently divided into three types: two-parent families consisting of bothbiological parents; two-parent families with step-parents; and disrupted families/familiesconsisting of other relatives. To assess the socioeconomic situation that the adolescents (andby extension their families) found themselves in, the following question was used: “Tell me,please: How satisfied are you with your economic conditions at the present time?”Respondents who answered either “fully satisfied” or “rather satisfied” were classified asbeing materially satisfied. Information on maternal smoking was obtained directlyfrom theadolescents’ mothers. The mothers were subsequently classified as being current (defined asweekly smoking), former or never smokers. We did not examine paternal smoking because ofthe high frequency of absent fathers.

To ascertain whether the adolescents drank alcohol they were asked, “In the last 30 days haveyou consumed alcoholic beverages?” Those who answered “yes” are classified as users ofalcohol in this study. Information was also obtained about the degree of physical exercise theadolescents engaged in each week. Those who undertook any regular activity during out-of-school hours (ranging from light [i.e. less than 3 times per week] through to intensive [at least30 minutes a day] physical activity) are classified as being physically active. Data on the levelof self-esteem among the respondents was

obtainedby asking them if they agreed or disagreedwith the statement, “I think I don’t have many things to be proud of”. Those who agreed are

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classified as exhibiting low self-esteem. The adolescents were also classified in terms of theirplace of residence i.e. as coming from either urban or rural areas. Urban residence was furthersub-divided into those who came from the largest Metropolitan centres–

Moscow and St.Petersburg–

and those whocame from ‘other’ urban regions.

Statisticalanalysis

Details of the respondents’ baseline characteristics and the prevalence of smoking arepresented in Tab. 1. Chi-square tests were used to determine if there were significantdifferences between male and female sample characteristics and the prevalence of weeklysmoking. Logistic regression analysis was used to examine if any of the independent variablesdescribed above were associated with adolescent smoking, with males and females beingexamined separately. Two separate models are presented for each gender. In Model 1 bivariateanalyses (controlling only for age) were carried out, while in Model 2 multivariate analyseswere undertaken i.e. controlling for all the other variables in the model. As households ratherthan individuals were sampled, a Huber-White sandwich estimator was subsequently used toexamine the potential effects of data clustering on outcome estimates. The initial resultsremained unaffected and are thus presented.

Results

Sample size

and characteristics

The mean age of the adolescent respondents was 15.5 years (see Tab. 1). Most adolescentslived with their biological parents in two-parent families, although approximately a third hadno father living with them. Just over half of therespondents were satisfied with theireconomic circumstances (55.7 %), while the vast majority of the adolescents’ mothers hadnever smoked. Nearly one-quarter of all respondents had consumed alcohol in the previous

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month, and a slightly higher percentage(31.4 %), regularly engaged in physical activity.Nearly three-quarters of both boys and girls exhibited a low level of self-esteem. Finally, amajority of respondents lived in urban locations. There were no statistically significantdifferences observed between the sexes for any of these variables.

Prevalence of smoking

Across the whole of Russia 16.4 % of adolescents were current weekly smokers in 2004. Theprevalence of smoking was almost five times greater among boys compared to girls (26.1 %vs. 5.7%, p<0.000).

[Tab. 1 Here]

Factors associated with adolescent smoking

The factors associated with adolescent smoking are presented in Tab. 2.

From the age of 14with each passing year the odds of smoking doubled for boys and trebled for girls.

Theinfluence of residential location differed by sex. In the age adjusted model, living in urbanareas had a significant protective effect against smoking for boys (OR=0.51; CI: 0.31-0.81,while living in Moscow and St. Petersburg increased the odds of smoking for

girls (OR=4.07;CI: 1.20-13.78). In the fully adjusted model however, these odds ratios were attenuatedsomewhat and were no longer significant.Although socioeconomic position was notsignificant in Model 1, when all the other variables were adjusted for

in Model 2, beingdissatisfied with their economic circumstances increased the odds of smoking amongst girlsby over four times(OR=4.08; CI: 1.13-14.69). This suggests a strong interaction effect withother variables acting to amplify the effects of socioeconomic dissatisfaction.No significanteffect ofsocioeconomic dissatisfaction

was found among boys.

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For both sexes the use of alcohol was strongly associated with an increased risk of smoking(boys OR=3.91; CI: 2.13-7.15; girls OR=7.05; CI: 2.06-24.07). In contrast, other factorspredicted smoking among boys but not among girls: physical exercise during out-of-schoolhours had an important protective effect against smoking (OR=2.14; CI: 1.16-3.92 for thosewho were not physically active), while low self-esteem increased the odds of smoking by afactor of 2.66 (CI: 1.41-5.00). The probability of smoking was greater for adolescents whosemothers were current smokers, especially among girls (boys OR=2.43; CI: 1.21-4.89; girlsOR=9.51; CI: 2.42-37.37). Finally, living in a disrupted family or with other relativesincreased the odds of smoking for both sexes in Model 1 but in the fully adjusted model(Model 2) the result remained significant only for boys (OR=2.70; CI: 1.40-5.21).

[Tab. 2 Here]

Discussion

This study examined the prevalence of smoking and the factors associated with it amongadolescents aged 14-17 in the Russian Federation in 2004. Our finding that 26 % of boys areweekly smokers accords with the result from a study undertaken across a number of regions ofRussia in 2006 where 27 % of 15 year old boys were found to be weekly smokers. However,the prevalence ofweekly smoking we recorded among girls was much lower than in thisaforementioned study where 21% of 15 year old females were weeklysmokers (Currie et al.2008). This highlights one of the possible limitations of the current study–

that data werecollected within households rather than schools, which may have resulted in some girlsconcealing their true smoking status as it is still less culturally acceptable for females tosmoke in Russia (Kemppainen et al. 2006).

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The finding that smoking increases with age mirrors that from earlier studies in Russia (Pärnaet al. 2003), as does the much greater prevalence of smoking recorded amongboys comparedwith girls (McDermott et al. 1998). When girls’ and boys’ data were entered into the sameage-adjusted model it showed that boys were nearly 6.5 times more likely to be smokers(OR=6.41; CI: 3.19-10.51) (data not shown). This gender difference in adolescent smoking,has also been observed in other Eastern European countries (King et al. 1996), and reflects themarked gender differences seen in adult smoking. It has been suggested that it may result fromcultural beliefs about the acceptability

of smoking in Russia (Kemppainen et al. 2002).Alternatively, it may stem from the success of marketing in reinforcing the view in part basedon role models, that smoking is normal for adolescents males (McDermott et al. 1998), inmuch the same way as itis for men in Russia (Perlman et al. 2003). This notion concerningthe potential modelling and normalization of smoking gains support from the very high ratesof adult male smoking to which boys are exposed (around 60 % of adult males in Russiasmoke) (Perlman et al. 2007) and the numerous social situations in which smoking occurs inRussia. Moreover, a recent study has shown that children are comparatively more exposed toregular indoor tobacco smoke and paternal smoking in Russia than in some other countries(Hugg et al. 2008).

Greater smoking among boys may also be related to its social image (McDermott et al. 1998).We found a significantly greater frequency of smoking among adolescent boys with low self-esteem. Previous research has shown that Russianadolescents rate themselves much lower onthis measure when compared with children from other countries (Slobodskaya 1999). It hasbeen suggested that Russian children (especially boys) may develop low self-esteem as theyare subjected to frequent criticism, teachers fail to praise pupils for their efforts, and mothersappreciate their children’s social skills, abilities and performance of various activities less thanin other countries (Slobodskaya 1999). In such circumstances, it is possible that some boys

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may initiate smoking in an attempt to boost their social image–

especially as among manyschool children in Russia smoking is associated with being a ‘real’ man (Prokhorov andAlexandrov 1992) looking ‘cool’ and being more ‘grown up’ (Rogacheva et al. 2008). Inaddition, some previous research suggests that those with low self-esteem may also be unableto resist the social pressure from peers to start smoking (Carvajal et al. 2000). In Russiaadolescents have a significant amount of freedom as regards their peer relations and leisureactivities (Holloway et al. 2008) and best friend’s smoking is also a strong predictor ofadolescent smoking (Kemppainen et al. 2006).

Maternal smoking was associated with boys’ and especially, girls’ smoking. This associationhas been observed in an earlier study of adolescent smoking in Russia (Kemppainen et al.2006). Several ways have been proposed in which parents might influence children’ssmoking.For example, social learning theory (Bandura 1977) has emphasized the role ofmodelling in behaviour acquisition and it has subsequently been argued that this may beimportant in the initiation of smoking by children.Moreover, asmothers not only have agreater role in children’s socialization but also spend significantly more time with children,seeing their mother smoke may act to both normalize and legitimize smoking by adolescentgirls.

There is also the possibility of confounding by, for example, unmeasured dimensions ofdeprivation but as this would affect both sexes equally, the marked difference in the strengthof the relationship between boys and girls suggests that modelling is likely to be much moreimportant.

Smoking was also more common among those adolescent girls who reported that theireconomic position was less than satisfactory. Earlier research in Russia has linked materialdeprivation to smoking among adults (McKee et al. 1998), which suggests that adolescentsfrom poor families may be more likely to encounter negative parental role models. The fact

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that the effects of material dissatisfaction significantly increased when maternal smoking wasadded to the model (data not shown) suggest this may be the case.Other factors may also leadadolescents in a less than satisfactory economic position to experiment with cigarettes, such asthe stresses and strains that can result from poor material circumstances

(Wills et al. 2002).

The effects emanating from an unfavourable socioeconomic position might also be related toanother factor.Our results revealed that there is an association between adolescent smokingand family structure where a two-parent family with both biological parents being present wasa protective factor against smoking. This is an important finding as almost one-third of theadolescents in this study lived in disrupted families–

with many of them likely to be singleparent families headed by mothers, whose numbers have grown sharply in recent years inRussia (Lokshin et al. 2000). Households with such families are among the poorest incontemporary Russia (Lokshin et al. 2000).

There are several ways in which economicdisadvantage may interact with family structure to predict smoking.Poverty can impactnegatively for example, on the quality of parenting whichin turn,can be detrimental for thechild’s developmental wellbeing and behaviour

Both adolescent alcohol use and a lack of physical activity (among boys only) were closelyassociated with an increased risk of smoking. Lifestyles tend to cluster, so that individualswho adopt a healthy lifestyle with regard to one aspect of their lives also tend to do so inothers (Tyas and Pederson 1998). Beingphysically active during out-of-school hours mayalsomean thatthere are fewer opportunities for engaging in risky

behaviours such as smoking,drinking alcoholor excessive sedentary behaviour such asspending many hours in frontofa

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television (Collingwood et al. 1991).This may be an especially important factor in Russia,where socioeconomic transition following the collapse of communism has been accompaniedby aconsiderable reduction in the number of establishments for out-of-school activities forchildren and adolescents (such as sport clubs) that had been previously provided by the state.The substantial reduction of adolescent participation in organized activities since the Sovietperiod (Holloway et al. 2008)

has meant that many Russian adolescents spend their free time‘doing nothing’, ‘sitting at home’ and ‘walking’(Boitsova

2003). The street environment oftenserves as a meeting place away from parental supervision (especially for boys), whereexperimentation with tobacco, alcohol and other unsanctioned activities

occur (Boitsova

2003).

Place of residence was a strong predictor of adolescent smoking in Model

1, when adjustingfor age, with a different rural/urban gradient in the prevalence of smoking being seen amongadolescent boys and girls, i.e. boys in rural areas were generally more likely to smoke, whilesmoking among girls was significantly more common

in Moscow and St. Petersburg. Asimilar result has been obtained for the Russian adult population (Perlman et al. 2007)

andmost, if not all, post-Soviet surveys show that in countries where the tobacco industry hasbeen privatized urban residence is a major determinant of female smoking. This has beenspecifically linked to the privatized tobacco companies targeting young women and directingtheir initial marketing and distribution efforts at major cities (Perlman et al. 2007). Enteringthe variables into

the multivariate model in several stages revealed that among girls the effectof Moscow/St. Petersburg residence on cigarette smoking is mediated by maternal smoking,which as noted, previous research suggests will in turn be determined by place of residence.

Before concluding it is necessary to highlight several potential limitations of this study. Asmentioned above, data were collected from adolescents in the parental home and there were

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no biochemical checks (e.g. cotinine) undertaken to verify reported smoking status. This mayhave resulted in the underreporting of smoking status–

especially among girls (Kemppainenet al. 2006). Second, the cross-sectional nature of this study makes it impossible to determinecause and effect. For example, adolescent smoking may be a cause as well as a consequenceof low self-esteem,as the stigmatization of smokers may feed through to lower levels of self-esteem (Baumeister et al. 2003).

Third, we also had no information on some potentiallyimportant variables suchas familial/parent-child relations, parenting style and peer smokingwhich have previously been shown to be important predictors of adolescent smoking. Finally,another key issue is the small sample size which accounts for the wide confidence intervals.However, unlike many surveys of adolescent behaviour, we were able to link eachindividual’s reported smoking status to their family environment, showing that it is animportant influence, albeit one of many.

This study has shown that the prevalence of smoking varies widely between boys and girls.However, several factors are strongly predictive of smoking for both sexes across Russia. Inparticular, adolescent modelling of parental smoking (and other negative health behaviours)may be especially important.

As previous research has highlighted that smoking amongstyouth in Russia is associated with negative health outcomes even in adolescence (Prokhorovand Alexandrov 1992) addressing the issue of adolescent smoking is an urgent task from apublic health perspective. Our results, in conjunction with the findings from earlier studies(Kemppainen et al. 2006)

suggest that the parental home may be an especially important sitewhen it comes to both understanding adolescent smoking in Russia, and that any attempts

Moreover, as negative health behaviours seem to cluster this suggests that approaches to dealwith youth smoking should be linked to those used to reduce

alcohol use and physicalinactivity. Specifically, as evidence indicates that these behaviours begin to cluster amongchildren early in life, this highlights the need for comprehensive interventions in the form ofschool-based health education programmesthat are designed to counter a range of potentiallyharmful behaviours simultaneously, which should be implemented at an early age toencourage the emergence of a ‘positive health profile’ (Lytle et al. 1995).